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case study

Tuberculosis programmeIndian Red Cross Society

A volunteer of the Indian Red Cross So-ciety's TB programme runs an aware-ness session for a group of workers at the Coca-Cola factory in Amritsar, Punjab. Photo: Benoit Matsha-Carpentier / IFRC

IntroductionTuberculosis (TB) remains a major public health problem in India. India accounts for one-fifth of the global burden of TB. Each year nearly 2 million people in In-dia develop TB. Every three minutes, two people in India lose their lives due to TB, a disease that remains most common among poor marginalized portions of the population.

Almost 70 per cent of TB patients in India are aged between 15 and 54 years. While two thirds of overall cases are male, TB takes a disproportionately larger toll among young females, with more than 50 per cent of female cases occurring in women aged under 34 years old. TB also exacts a devastating social cost; according to a study published in the International Journal of Tuberculosis and Lung Disease in 1999, each year more than 300,000 children are forced to leave school due to stigmatization as a result of their parents having TB and as many as 100,000 women are rejected by their families due to their TB status.

Surveys have shown that prevalence rates of MDR TB (multi-drug resistant tubercu-losis) in India are 3 per cent among new

2International Federation of Red Cross and Red Crescent Societies

Indian Red Cross Society Tuberculousis programme

cases and 12 among retreatment cases. The true burden of MDR TB in India is unclear due to the absence of sufficient laboratory capacity to conduct appropri-ate testing.

Pilot programmeSince September 2009, the Indian Red Cross Society has focused its efforts on ensuring treatment adherence among the most vulnerable people living with TB, in particular, category II patients (see over-leaf for definition of cat II). The Red Cross played an important and complementary role by assisting the Government of India to implement its revised national tuber-culosis control programme, particularly at community level.

The pilot programme was executed in two phases. Initially, phase I was part of the pilot study for the TB project which was carried out from October 2009 to September 2010. This was a preparatory phase whereby a baseline assessment was carried out across each of the three states in order to identify priority areas for programme implementation, recruit-ment of staff and execution of the pro-gramme. After successful completion of the phase I pilot study, the project was ex-

tended into phase II, which included the implementation of project activities from December 2010 until November 2011, to-gether with an increase in the number of CAT-II patients supported from 35 to 50 per programme district. In this phase, the total number of patients targeted was in-creased to 301 across three states; Karna-taka, Punjab and Uttar Pradesh.

Vulnerability and the needs of communi-ties were taken into consideration in the selection of the states for the project. The areas chosen were categorized into urban slums, semi-urban industrial, and rural areas connected by rail and road from the state branch offices. Two districts in each state were selected.

ObjectivesThe project had three main objectives:1. To provide care and support for treat-

ment adherence to 300 most-vulner-able retreatment TB patients (as well as support to 1,200 family members).

2. To increase community awareness on TB, MDR TB and TB/HIV through project advocacy, information, educa-tion and communication, and social mobilization.

3. To reduce stigma and discrimination towards TB and TB/HIV patients and their family members.

Partnership and cooperationIn addition to donor agencies supporting the programme, including USAID and the IFRC, the key partner of the Indian Red Cross Society in this programme has been the ministry of health. Rather than trying to establish an independent initiative, the Red Cross has complimented the work of India's ministry of health, and working in close partnership, identified patients at risk of default on their treatment. Red Cross volunteers were assigned patients to support through home visits, as well as assisting them in reaching medical cen-tres as per their treatment schedule and ensuring the provision of supplimentary nutrition support.

Indian Red Cross also runs information sessions for families of those receiving treatment for TB, as well as the broader public. Photo: Benoit Matsha-Carpentier / IFRC

3International Federation of Red Cross and Red Crescent Societies

Indian Red Cross Society Tuberculosis programme

Through its network of community based volunteers, the Indian Red Cross Society has chosen to go the last mile with pa-tients who are most vulnerable due to their economic and social conditions as well as their TB status. By focusing on those who would otherwise fall through the treatment net due to a variety of rea-sons, the contribution of this pilot pro-gramme toward curing TB and preventing further transmission, is not only signifi-cant, but ground breaking in its approach.

In an effort to increase the number of volunteers who understand the perspec-tive of a TB patient, those who have been cured through this programme are active-ly encouraged to become volunteers, and further break the cycle of transmission in their own community.

SuccessesAlthough a small number of patients re-ceive support through this programme, they are among those who find access to treatment the most challenging, either for economic reasons or because of the significant stigma placed on those living with TB. By offering support and arranging transport to treatment and testing where necessary, this Indian Red Cross Society programme has resulted in an extremely high adherence rate of patients to treat-ment; 92.69 per cent in 2011, up from 90 per cent the previous year. This far ex-ceeds the minimum objective for govern-ment lead programmes, set at 70 per cent or more. In addition, these figures issued by Red Cross branches have been further validated by the ministry of health and the WHO, ensuring their accuracy.

From September 2011, with the support of DFID, Indian Red Cross Society was able to further extend the programme to two additional districts in the state of Gu-jarat. The TB division of India's ministry of health has extended all possible support to Red Cross volunteers throughout the pilot phase of the project.

During this pilot period, state and district branches have build their own capacity in community focused programme im-plementation. Branches have also gained experience in tackling issues of stigma through this programme, by running pub-lic information sessions and collaborating with corporate organizations to ensure their staff are informed of suitable respi-ratory etiquette as well as using the oppor-tunity to reduce stigma through accurate information. Almost 65,000 people were directly informed about TB and related is-sues through 320 community meetings, as well as interactive sessions such as street theatre.

ChallengesAs the programme has until now been de-livered on a pilot basis, there have been normal challenges and delays. Looking to the future however, two main issues will need to be addressed for successful im-plementation and replication throughout other targeted districts:

• Sustainability: Funding for projects such as this must be assured before commencement of treatment. Long term funding remains difficult to ac-

What is category II?

Patients with category II pulmonary

tuberculosis include those who had

failed previous TB treatment, relapsed after treatment, or

defaulted during previous treatment.

TB is confirmed through laboratory testing of sputum samples of the patient. These tests are carried out rapidly, so that the patient quickly learns his or her status, and can begin treatment if necessary.

Photo: Benoit Matsha-Carpentier / IFRC

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cess; a major challenges to increasing the reach of this programme.

• Protectionofvolunteers: Although all those involved in the project are well informed about respiratory etiquette, TB is a communicable disease – vol-unteers must be well protected, while avoiding any increase in stigma.

The futureDeputy director general - TB of the Indian ministry of health recommended that this project be scaled up throughout other key states in India. With the Indian Red Cross Society plans to expand the programme in two districts each of Haryana, Bihar, Odis-ha and Maharastra, in addition to Gujarat, Karnataka, Punjab and Uttar Pradesh.

Collaboration and partnership with gov-ernment agencies, as shown in this pro-gramme, underline the added value that the Red Cross can bring when responding to health issues. Traditionally perceived by the public as a leader in community health, the government of India now fur-

ther recognizes the important role that the Red Cross can plan, in particular with those at the fringes of society. Indian Red Cross will continue to show that as part of communities across the sub-continent, it is perfectly placed to respond to com-munity issues.

Clockwise from above:

1. Sardam, a volunteer of the Indian Red Cross makes a home visit to ensure that those the programme supports are continuing their treatment.

2. Ram Assary is a migrant and was a category II TB patient. When he started his treatment, he had a bad reaction, developing infection in his legs and stopped treatment. He was brought to the TB centre by a Red Cross volunteer, restarted treatment and is now cured, recovering the use of his legs. During the whole phase of the treatment the volunteer was bringing him the rugs at home as he could not walk.

3. Gopal (28) has been supported throughout his treatment by the Indian Red Cross Society. Gopal is a migrant from Bihar. He moved to Punjab when only 10 years old, seeking work.

Photos: Benoit Matsha-Carpentier / IFRC

• Mr.JohnRoche-Head,IFRCIndiaofficeE-mail:john.roche@ifrc.org

• Dr.Dr.KailashRaizada-SeniorAdvisor,IFRCIndiaofficeE-mail:k.raizada@ifrc.org

• Dr.A.K.Dash-NationalTBProgrammeCoordinator,IndianRedCrossSocietyTel:+911123716441/2/3

Contact information